Like many teenagers in rural Ethiopia, Shekuria Mume, 19, became pregnant, quit school and got married at 15. The birth of her first baby remains one of her most traumatic experiences, as an untrained traditional birth attendant (TBA) delivered her.
"I had heard that some women die while giving birth so I was scared most of the time during my pregnancy; I didn't sleep much," Shekuria told IRIN.
With no health facility near her village of Shuna, in West Hararghe zone of Oromiya state, Shekuria relied on a TBA. She was in labour for two days.
"The attendant kept checking my progress using her bare hands; when I gave birth, she used dirty sheets to wrap up the baby," Shekuria recalled.
Although Shekuria survived, many Ethiopian women are not so lucky. According to the 2005 Demographic and Health Survey, the country has one of the highest maternal mortality rates in the world, with 673 deaths per 100,000 live births.
The UN Population Fund (UNFPA) estimates that 25,000 maternal deaths occur in Ethiopia annually and at least 500,000 women suffer pregnancy-related disabilities such as fistula.
After giving birth, Shekuria and her husband moved to the town of Chelenko, about 440km east of Addis Ababa. Here, she had access to family planning.
Now 19, Shekuria decided to have another baby. When she went into labour, the TBA, Fate Adem, 65, was called to assist.
This time, Shekuria was expecting twins and experienced complications. Luckily, Fate was one of 80 graduates of safe delivery techniques and referred Shekuria to Harar Hospital nearby.
"She was bleeding too much," Fate told IRIN. "Following my training, I brought her to the hospital."
Shekuria safely delivered the babies and is now planning to resume her schooling.
Dearth of midwives
Fate received her TBA training courtesy of the International Medical Corps (IMC) and UNFPA's joint reproductive health response in drought-affected areas of East and West Hararghe zones of Oromiya region.
TBAs are crucial in a country such as Ethiopia, which has the lowest number of trained midwives in sub-Saharan Africa. According to UNFPA, there is only one nurse or midwife for every 62,000 Ethiopians.
"Though medical birth attendance in health facilities is the best way to prevent and address delivery-related complications, in communities where most of the women deliver at home, traditional birth attendants have proven a critical stop-gap," a UNFPA document stated.
A high maternal mortality rate, coupled with a high under-five mortality rate - 123 children per 1,000 live births – means Ethiopia is far from achieving the Millennium Development Goal to cut maternal mortality by more than half and children's deaths by half.
At least 80,000 beneficiaries of the UNFPA-IMC project live in East and West Hararghe zones, where some change has become evident.
Yusuf Ibrahim, head of the health department in Meta woreda, where Shekuria and Fate live, said maternal mortality had decreased. The situation was similar in West Hararghe zone, where 88 percent of mothers delivered their children with the help of health workers or trained TBAs.
"Our assessment showed TBAs assisted 2,652 mothers to have safe deliveries in East Hararghe," Marefia Mamo, the project coordinator for IMC, said.
Agents of change
Yusuf said besides helping in safe delivery, TBAs were "agents of change", who advocate within the community for better health practices.
"Our people do not have enough awareness on contraceptive use; they give birth year after year and the attendants have tried to teach them better practices," Yusuf said.
Fate said some of the tasks she had taken on since graduation included informing mothers about hygiene, vaccination, regular health check-ups at health centres and the importance of a balanced diet.
Shekuria said she had taken the advice seriously, especially on family planning. As a result, she and her husband had decided not to have another baby until she completes high school.